2.1 Sample

A convenience sample of 42 nurses recruited from three Health Centres (HC) of a Health Centre Grouping in the northern region of Portugal was used, intended to involve all nurses working in these health units.

All nurses from the Personalized Health Care Units of the health centres involved in this study were willing to participate. Participants were mainly women (85.71%; n=36), aged between 28 and 59 years (M=44.19; PD=7.43), time of professional experience between 6 and 40 years (M=20.27; PD=7.21). Graduate nurses and specialist nurses were the most prevalent professional categories found (42.86%; n=18).

2.2 Data collection

The data collection was carried out through a semi-structured interview including a script with five major themes: the first theme addressed ethical considerations and the study proposed objectives; the subsequent themes included questions related to the conceptions, representations and opinions of the participants about CS in nursing.

2.3 Data analysis

The interviews were recorded on audio and transcribed in full as they were conducted. The Nvivo10® program was used to codify each interview. Content analysis was carried out according to the principles of the grounded theory method (^{Strauss & Corbin, 2008}). After the analysis of each interview, fieldwork was done whenever deemed necessary to validate the information.

3. Results

From the analysis, the category "Critical-reflexive analysis of practices” emerged, which refers to one of the current CS strategies, with identified dimensions and subcategories (Figure 1).

The dimensions identified were the intrapersonal dimension - from which the subcategories low self-reflection, and absence of formal strategies of critical thinking development emerged -, and interpersonal dimension - from which emerged the subcategories occasional, lack of time for interpersonal reflection, organisation of work interferes with interpersonal reflection, the difficulty of interpersonal reflection in health units exposes areas of (not) knowledge, low predisposition to interpersonal reflection, head nurse facilitates interpersonal reflection, interpersonal reflection at service meetings, and reflection between supervisors of different services.

Figure 1 Critical-reflexive analysis of current practices: dimensions and categories 

4.1 Intrapersonal dimension

This critical-reflexive analysis dimension refers to individual reflection, consisting of an intra-personal component identified by ^{Schön (1987}) as the "silent game", a reflexive process compared to an individual "solitary game", of a dynamic feature that generates unpredictability, underlying the fascination for problem-solving. Contrarily to this dynamic is the opinion of one of the participants, who perceived some "routine" installed in the service likely related to the lack of intrapersonal reflection, questioning and problematization of practices, meaning little self-reflection:

(...) it turns out that the majority of us are already accustomed to current practices (...) we got used to the routine, to perform all those tasks without reflecting much on what we do. Is there anyone who at the end of the working day (...) reflects or questions his or her day-to-day work? Is there anyone? I don’t believe so! E9CH

This result corroborates the findings of ^{Netto, Silva & Rua's (2018}, p.2) that "technical reasoning mindset, normative curriculum, application of theory and technique derived from mainly systematic scientific knowledge, the epistemology of practice, and the still existing gap between teaching, research and practice, mostly in universities, leave no space for reflexive action and hinder professional competence".

This metacognitive capacity is vital since it allows nurses to become aware of the processes underlying their professional activity. Thus, the guided reflexive practice in CS promotes introspection, stimulating critical-reflexive thinking about clinical experiences and underlying scientific evidence (^{Gates & Sendiack, 2017}). The reflexive practice is important because it is a specific working method, intended to allow the professional to build knowledge based on his/her practice. This method is defined as the "art of intrinsic growth" through reflection, with the purpose of finding a solution (^{Netto et al., 2018}).

Regarding the absence of formal strategies for the development of critical thinking (…) there's a more informal strategy for the development of critical thinking. E16VP

The study by ^{Dubé & Ducharem (2015}) showed that the working culture of some health units does not encourages reflexive nursing practices. ^{Gates & Sendiack (2017}) noted that a reflexive environment provides the opportunity to reflexive thinking within the supervisory context, allowing supervisors to meet both the supervised and the client’s needs. It also provides a solid structure that facilitates reflexive practice, supports the development of technical skills and critical thinking, and ultimately encourages the development of personal and professional identity. The same authors argue that the existence of a formal reflexive environment within the organisation promotes a sense of conscious introspection of professionals allowing the development of mastery of practice over time, including ethical considerations and clinical wisdom.

4.2 Interpersonal dimension

The interpersonal dimension of critical-reflexive analysis refers to hetero-reflection, a dyad reflection carried out within groups, which ^{Schön (1987}) identified as the “interplay", implying an attitude of intellectual humility, recognizing that "the other" can substantially improve our knowledge.

The participants identified the presence of reflexive practices among peers:

We engage in reflection among colleagues! Well, some are more engaged than others! But we share information and knowledge (…) E2RP; (…) we discuss our patients’ cases daily and the experienced difficulties. (...) not only with colleagues but with supervisors. It seems to me that we already do some supervision work. We talk about things that go well and those not that good, discuss situations where we could be more committed and why this doesn’t happen sometimes. E5RP

However, they consider that interpersonal reflection is occasional, non-formal:

(...) it happens occasionally. We have no specific moments for that. E13CH; Sometimes, when we’re faced with a new situation, that someone else has already experienced, we sit down and discuss it informally. E14VP; I really think we already do that informally. E4RP

Also, ^{Tavares (2013}) concluded that the nurses recognized the existence of critical-reflexive analysis practices in their services, despite its informal character. However, they considered that reflexive processes including the sharing of knowledge, experiences, and points of view among colleagues resulted in individual and collective enrichment, ultimately benefiting the client by developing action strategies discussed and reflected among peers. However, ^{Süleyman & Bozkuş (2017}) argue that being reflexive should constitute a vital component of daily life, not a separate and unrelated action from practices.

Despite the informality in implementing this CS strategy, ^{Rocha (2013}) concluded that this was the fifth most frequently implemented in health services. However, this strategy emerged in the sixth position concerning the willingness of frequency to adopt it.

In view of the difficulties expressed by participants in finding time for reflexive analysis of practices among peers, the subcategory lack of time for interpersonal reflection emerged:

(…) The problem is having time for that, (…). Lately, we haven’t had the opportunity to share and reflect on our practices, and we used to have it (…). We have fewer opportunities for reflection among us. E8CH; I would really like to have more time! E5CH

Time is a factor that can influence the conditions for reflexive analysis of practices, and informality seems also to hinder this factor, "leaving matters for a later discussion", and overlapping tasks considered "more important".

The studies conducted by ^{Cross, Moore, Sampson, Kitch & Ockerby (2012}) and ^{Tavares (2013}) also showed that the CS in nursing is particularly important in services where nurses are more affected by work overload, so time should be provided to reflect on their practices and professional issues.

CS is based on reflection since the whole supervisory process is only relevant because it integrates reflexive processes, so the provision of time for CS in nursing and related training must inevitably include time for reflection on practices and contexts (^{Dubé & Ducharem, 2015}; ^{Snowdon et al., 2017}).

Another emerging aspect pertaining to reflection was the organisation of work, the subcategory - organisation of work interferes with interpersonal reflection, which somewhat relates to the previous one:

We often don’t have the opportunity to reflect with each other on practices because we´re working isolated, in separate stations. E11CH; There is little sharing! (…) our organization of work doesn’t help! E1CH; (…) it also depends on the department and schedules. There are days (…) we discuss some things. But then, this colleague works until seven, the other until five... or is alone on that shift (...). Meaning, we´re aware of what our closest colleague id doing, (...) and that’s whom we talk with. (…) we would have to organize! (…). E2CH; (…) The organization of work doesn't leave much space to discuss things with all our colleagues. (…) I think this is mostly due to the organization of work. E4RP

^{Süleyman & Bozkuş (2017}) state that the reflection promoted by an organization's culture and structures affects and is affected by choices, policies, decisions and work.

The participants also referred to the shift change as a privileged moment for reflection on practices. They also consider that nurses highly benefit from the time provided by the organisation of work to engage in discussions about the client’s condition and the provision of care, and thus a new subcategory emerged - reflection during a shift change:

We have less time to reflect. It's not like in the hospital, every day, during shift change (...). E1CH; (...) I know that in some hospital services and other health centres this is possible during shift change, but here we don’t have that time. (…) we really need to talk more about care. (...) we haven’t that kind of meetings. Sometimes we’re not able to discuss things, and this is important. E4CH

These perspectives corroborate the findings of ^{Tavares' (2013}), which identified daily practice situations conducive to reflection, individually or collectively, highlighting the importance attributed by participants to analysis, discussions, and reflections that took place during shift change considered cardinal for the development of reflexive practice. Shift change is highlighted as an important time to reflect on practice and assess the best strategy for a specific situation, emphasizing the shared and discussed information.

^{Rocha, Reis Santos & Pires (2017}) also concluded that hospital nurses reported more sharing opportunities, particularly at shift change.

Another identified sub-category points to the influence of individual characteristics that the participants recognised in some colleagues, which may condition reflection - low predisposition for interpersonal reflection:

Some colleagues make reflection more difficult. (...) it's no use... because then he insists that he’s right. Some colleagues are not open to discussions, so they always think they’re right! (…). I’m not sure they understand they’re missing out the opportunity of learning with colleagues! They think they’re always right. E1VP; Some find it more difficult to ask colleagues for an opinion about the provision of care! (…) some colleagues find reflection more difficult! (…) the most conservative colleagues find it more difficult to discuss provision of care among colleagues. E3VP; (…) there’s always someone that doesn’t enjoy doing it! Isn’t it? E5CH

According to ^{Sá-Chaves (2000}), the transition to the "solidarity self" is not easy. The difficulty of reflecting openly with the other can be rooted in personality traits/communicational skills, lack of time and other personal or organizational constraints. Despite the attenuating effects of the lack of a reflexive "culture" underpinned by paradigmatic issues, its marked influence until the 1980s somehow seems to linger.

In the study conducted by ^{Pires (2004}), reflection on practices among nurses was mentioned as one of the daily socio-clinical difficulties, namely some resistance to reflexive practice. Some professionals considered they had universal truth, unwilling to discuss it with their colleagues.

Also, the subcategory - exposes areas of (not) knowledge has also emerged. The participants perceived that the knowledge deficit could be identified through interpersonal reflection:

I ask for my colleague’s opinion on knowledge, to see if I’ve got the correct information. They help me understand if I’ve sufficient knowledge. E13VP

This finding is in line with the work developed by ^{Süleyman & Bozkuş (2017}), who considered interpersonal reflection a way of learning, and a "double-loop", a process of shared cognitive learning. The participants helped each other identify difficulties and find targeted strategies, thus broadening their perspectives on problem-solving (expanding knowledge) and acquiring new insights into behaviour (change of attitude).

The difficulty of interpersonal reflection in health units was also mentioned, which stems from the lack of discussion among peers, also due to the more isolated working characteristics:

(...) we’re physically distant from the main services, so it’s more difficult to engage in reflection with colleagues. E9VP

The geographical distance between health units and the main unit was identified as one of the factors hampering CS and peer reflection, adding to working places with a single nurse. This finding corroborates the study by ^{Rocha, Reis Santos & Pires (2016)}, suggesting the existence of contexts where direct contact between professionals is difficult due to geographical distance, particularly between colleagues and/or supervisor and supervised. This particular situation hinders the supervision process and reflection and often suggests implementing CS strategies at a distance.

Studies involving environmental, demographic characteristics showed significant differences in the organisation of CS in hospital and community contexts, precisely due to the greater dispersion of professionals in the second context (^{Lynch, Hancox, Happel & Parker, 2008}).

Although the participants identified some difficulties and informal/occasional reflection of practices, they pointed out the benefits of service meetings, more formal programmed moments, thus emerging the subcategory - interpersonal reflection at service meetings:

We all take advantage of service meetings to reflect on care provision and ask some questions. If we have some difficulties we share them with colleagues and try to clarify them (…). E11CH; We engage in reflection among us. We try to! Usually we go to meetings and take this opportunity to be with colleagues from the main unit and discuss strategies. E11VP; We share opinions and discuss care provision at our meetings. We already do that! (…) we have these meetings to share our doubts. Sometimes it´s good to disagree! E13VP; We always reflect on care and clinical records at monthly meetings. E15CH

The relevance of reflection to the progressive improvement of nursing care provides nurses with the opportunity to reflect on their practices in meetings held exclusively for this purpose (^{Cross et al., 2012}; ^{Tavares, 2013}).

Reflection among supervisors of different services was another identified subcategory.

There is some solidarity between colleagues, (from different CS) and peers with the same role [supervisor], we share and help each other. E7RP

The study of ^{Cruz (2012}) also highlighted the reflection between supervisors of different services through "indirect supervision" through team meetings of clinical supervision, intending to share information and standardise their actions. ^{Borges (2013}) found that participants stressed the importance of supervisors' meetings as they provide a greater support level.

Another subcategory identified was - head nurse facilitates interpersonal reflection:

(...) the head nurse provides us with the opportunity to meet with each other and share experiences. E7VP; I always encourage interaction in meetings. (...) I encourage the team's reflection and critical thinking. E15CH

The study by ^{Pinto, Reis Santos & Pires (2017}) showed that the supervisor plays a pivotal role in training reflexive professionals by mobilising targeted strategies. Since Portugal does not have formal CS programmes implemented in health services, it is assumed that the head nurse plays this role. In the study conducted by ^{Tavares (2013}), the head nurse was found to have a relevant role in stimulating the critical-reflexive analysis of practices, encouraging the nursing team to reflect for-, in-, and on-action, and in the performance as a supervisor, acting as a catalyst for reflexive practice, focusing on improving care. The nurses considered that the team mirrored their leadership, concerning reflection, because their demand impelled the team to become more demanding, making them accountable for self-development and encouraging professional accomplishments.

^{Süleyman & Bozkuş (2017}) considered that reflection is a way of learning and that its management is an essential goal in creating reflexive teams, aiming to provide strong and equitable learning opportunities for everyone within the organisations, and encourage benefits from these opportunities. In this sense, they understand that managers can contribute by committing themselves to focus on learning, training professionals and developing ways of overcoming inquiring skills to develop mental behaviours for additional and autonomous learning.